Clinical documentation is increasingly being recorded, either partially or completely, using electronic documentation systems. This type of documentation occurs via a computerized device such as a desktop computer, laptop, tablet, and sometimes a smartphone. In order to access the system, healthcare professionals must sign in with a username and password that is unique to them. This security feature is a benefit of electronic systems in comparison to paper charting because it identifies who enters the client’s record and also restricts who enters the system. Also, this security feature helps protect the client’s privacy with electronic systems in comparison to written records.
Common electronic documentation systems used in healthcare settings include electronic medical records (EMR) and electronic health records (EHR).
EMRs are used and sometimes built for a single organization or practice, with a focus on the collection of medical data (e.g., specific to physicians). Common examples include electronic documentation systems used in the practices and clinics of primary care providers that do not connect to systems outside of those organizations.
EHRs are generally developed with interoperability as a key function, meaning that all providers who use the same health information system can access and exchange information across organizations and providers.
In general, recent trends have been favouring the development and use of EHRs, and the following sections focus specifically on these systems.
Purpose and vision of EHRs
The primary aim of EHRs is to facilitate seamless care for clients by providing a way to capture and access real-time client data. EHRs can improve interprofessional communication, coordinate care among providers, and foster effectiveness and efficiency in care.
EHRs can help eliminate gaps in care that can arise from the inability to share information across institutions and/or geographic boundaries. These systems provide access to longitudinal and comprehensive health records of clients, along with documentation and other clinical tools to support care provision by individual healthcare providers and teams.
An unconscious client is brought to the emergency department. The nurse reviews the client’s EHR and notes that they have recently been seen by a community cardiologist for chest pain; the nurse also notes that the client is allergic to aspirin (ASA). The emergency physician reads the client’s recently prescribed medications and diagnostic imaging from their consult with the cardiologist. Together, this information allows the healthcare team to make informed decisions about the client’s care, based on their individual history and detailed list of recent interventions. As a result, the client’s prognosis improves, the length of stay in hospital is reduced, and fewer resources are required to determine a baseline or for the client.
Commonly used EHR vendors
You will encounter numerous types of EHRs during your clinical placements and future practice. These EHRs vary in their functionality, look, feel, and usability. Healthcare organizations purchase an EHR system from a vendor based on their needs, capacity, and type of care provision (acute, public health, long-term care, primary care).
Common EHRs used in acute Canadian health settings include those built by large private vendors such as: EPIC, Cerner, Meditech, and Allscripts. Some healthcare organizations have built their own EHR systems (e.g., the Electronic Patient Record System developed by the University Health Network in Toronto). Other vendors are used outside of acute care (e.g., PointClickCare is commonly used in long-term care facilities).
Given the variability in vendors used in different organizations and care settings, what is most important for clinical documentation is to recognize the components of EHRs that are common across different types of systems. Although you are expected to understand and know how to use EHRs in organizations where you are placed or where you work, you will first receive orientation and training at these specific organizations.
Common components of EHRs
EHRs are digitized versions of paper charts, and they all include information similar to that collected for paper charts, as discussed above. However, because they are electronic, they also have functions that allow for data entry, viewing, and exchange of various types of client information (e.g., health history, progress notes, diagnostic and laboratory results, therapeutic orders).
Both electronic and paper charts use and , as outlined in Table 2. However, a key difference in clinical documentation is that the technological capacity of an EHR allows structured data to be easily aggregated and analyzed.
Table 2: Structured and unstructured data elements
Consideration and Examples
Structured data elements: These are built-in templates or structures that guide healthcare providers when entering data. They require providers to fill out specific fields (e.g., vital signs, medication dose), often by selecting a system-provided option. In the context of an EHR, structured data have inherent meaning and can be used in meaningful ways in other functions of the EHR (e.g., trending data, triggering warnings or reminders).
Example 1: A nurse enters the value of 140/80 in the EHR data entry field titled “blood pressure.” The EHR recognizes “140” as meaning systolic blood pressure in millimetres of mercury and “80” as meaning diastolic blood pressure in millimetres of mercury.
Example 2: The nurse begins to document a wound assessment. As the nurse begins to type wound odour in the wound assessment data entry field, the system provides automated suggestions in a drop-down menu including no odour, increasing malodour, and foul odour, and the nurse selects one.
Unstructured data elements: These are free-text entry sections that allow open-ended documentation of the client data. They may include progress notes and nurses’ notes, given the narrative nature of these types of documentation. Documentation of unstructured data involves the same principles as those used for paper charts (communication, accountability, and security, as discussed in the next section). Due to technological limitations, this unstructured information cannot currently be used in a meaningful way by the EHR in other functions. EHRs are currently unable to summarize or identify trends in these data, but this is an area of emergent research and methods are being developed to allow systems to understand unstructured narrative data.
Example 1: The nurse enters a note: “The client described walking for twenty minutes a day with no shortness of breath. The client uses a cane to support their balance.” This is unstructured in that the system does not have a way of understanding the meaning of any data entered in this field (e.g., whether it relates to mobility, nutrition, allergies).
Status of EHR
EHR deployment, maturity, and use varies among organizations, provinces, and territories. It is important to note that EHRs are not simple replacements of paper records: EHRs affect workflow significantly in terms of how nurses work, document, and manage information.
Activity: Check Your Understanding
The process of determining the possible causes or diseases for the presenting symptoms.
Refer to built-in templates or structures that guide the type of data to be entered in a specific field.
Refer to free-text entry that allows for the open-ended documentation of client data.